Conduct training and workshops on claims management system & investigative toolsEnsure there is high organizational claims qualityProvide detailed analysis of the claims handled by the claims adjustersProvide feedback on any areas of opportunity for timeliness, accuracy, and documentation. Focus on reduction of severityParticipate in at least one professional development training/course within each quarter.Maintain 90% or greater audit accuracy rateCreate training material to develop adjusters especially in the areas of Personal Injury Protection(PIP) and coverage investigationLead and manage special projects/assignmentsEngage in company and unit activities embody the core values of the organization and to build better relationships with my peers Manage the resources in a cost effective wayCollaborate with other co-workers on projects to meet the overall objectives of the organization

 Review claims and prepare dispositions on those claims that are scheduled for an Examination Under Oath(EUO) Conduct investigative searches such as ISO, Accurint, internet search, to fully prepare for the Examination Under Oath Ask a series a questions to both claimants and insureds regarding coverage, the policy application, injuries, treatment, facts of loss and employment history, in order to complete a proper and fully detailed investigation  Prepare a clear, well organized and documented summary of the findings from the EUO Maintain an open line of communication with team members and manager regarding hurdles and areas of improvement Submit recommendations to the claims adjuster and/or supervisor regarding coverage issues and/or potential fraud Update the EUO records to reflect whether or not an examinee has appeared for the EUO Conduct EUOs both telephonically and in-person Upload the recording(s) and supporting documentation related to the EUO such as the driver’s license Prepare for depositions by completing a review of the file, printing the necessary claims documents, organizing those documents and meeting with in-house counsel Attend depositions once every two months Occasionally assist teammates with their claims documents, closures and denial letters Respond to email communications and documents received on claims I previously handled Follow guidelines, procedures, policies and regulations Engage in skills development through Windhaven University Windhaven University courses passed: Project Management, MySQL, Introduction to Fraud & Policy Jacket Review Maintain a zero defect rate while producing at or above expectations

 Reviewed claims and determined coverage issue(s) Processed payments, litigated claims, and settled claims pre-suit Answered interrogatories, attended depositions and attended trials as an expert witness Oversaw 8 individuals within the unit to ensure quality control Maximized output performance and stimulated motivation Provided recommendations on files based on cost-effectiveness by reviewing the totality of the circumstances Provided recommendations regarding additional hardware or software for the unit Attended executive committees for implementation of new processes, brainstorm innovative ideas and discussed the hurdles we encountered Lead huddles and unit meetings on a daily basis Provided training on software such as OSIS, Accurint and ISO to new employees Conducted monthly performance management meetings with team members Provided monthly goals and metrics to team members to gauge performance Provided training for new processes and/or change in policies or procedures Participated in collaboration with the unit in company events such as School Supplies Drive Collaborated with managers of other departments to create together standards, procedures and policies Collaborated with the Business Analytics Department to create metrics for the coverage investigation department Collaborated with the Business Analytics Department to create a business process map and flow chart to increase efficiency and effectiveness Participated in the time study of actions taken from the reporting of a claim till the resolution of the claim. Formally presented recommendations to leadership for change in processes using objective data and subjective input compiled by the front-line workers

 Reviewed, negotiated and settled claims Qualified claimants/insured’s for coverage amongst many states Licensed to adjust claims in many states including but not limited to Texas Reviewed demands for payment or possible settlement Reviewed vehicle estimates/photos Determined liability based on investigation findings Used tools such as ISO, Mitchells, Clear and Accurint for investigative purposes Obtained recorded statements on all parties Software used: performance claims, Mitchells, hertz rent-a-car, enterprise, Clear, Lexis Nexis Accurint, ISO

 Reviewed claims and determined coverage issue(s) Processed payments, litigated claims, and settled claims pre-suit Answered interrogatories, attended depositions and attended trials as an expert witness Printer troubleshooting, scanner installation, scanner troubleshooting, operating system troubleshooting, software troubleshooting, and network printer installation Handled the workstation setup, the hardware replacement, troubleshooting and the user account management

 Examined and evaluated claims for payment Approved or denied claims as appropriate Initiated payment actions and made adjustment to bills/CPT codes if applicable Investigated claims for compensability, potential subrogation and possible fraud Obtained recorded statements and other evidence Obtained second opinion by way of an Independent Medical Examination(IME) and/or Peer review report Requested outside investigations, surveillance or other actions as needed Conducted negotiations for settlement of claims with either claimants, attorneys or medical facilities Provided customer service by answering and returning phone calls within 24 hours Paid reasonable, related and necessary claims Attended depositions and trials on cases that were litigated

 Worked hands on with a program, Powertrak, which applies the applicable fee schedule to bills, where applicable. Cross referenced other sources to ensure that the amounts per CPT code were being paid properly.  Corrected any issues within the system that appeared on a claim.  Worked with Guidewire, a claims management system, that was integrated with Spyware, an imaging documents software.

 Received new claims on behalf of the licensed adjusters within the company for the Personal Injury Protection (PIP) department.  Requested documents such as police reports, contact letters, PIP packages and any documents necessary to properly process the claim. Initial contact to all parties involved in each loss in an effort to obtain as much facts of the claim as possible.

 Obtained EUOs for the PIP department for numerous claims(qualification, potential fraud and potential coverage issues) Provided a detailed summary of the EUO and sent the summary to the assigned adjuster as well as a copy to imaging  Reviewed all facts on a claim such as bills, attorney mail, notes, etc. in effort to determine how to conduct the EUO for the claim in question.